=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265486849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FEATHERSTONE PARTNERSHIP LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 10/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1016 FEATHERSTONE RD
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-5902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-226-3300
-----------------------------------------------------
Fax | 815-226-9990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4661
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61110-4661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-226-3300
-----------------------------------------------------
Fax | 815-226-9990
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. STEVEN GUNDERSON
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 815-231-5450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 7001928
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------